Form 1040A United States Individual Income Tax Return 2011

Summary: This is an example of Form 1040A (2011) with these line items completed as would pertain to the
text.

Under
Label:

Your first name and initial field contains Joshua A.

Last name field contains Blake

Your social security number field contains 111-00-1111

Home address (number and street). If you have a Post Office box, see
instructions. field contains 1040A Main Street

City, town or post office, state, and ZIP code. If you have a foreign address, see
instructions. field contains Hometown, Arizona 85240

Presidential Election Campaign

Do you, or your spouse if filing a joint return, want $3 to go to this fund? You: Yes Note. Checking Yes will not change your tax or reduce your refund. Do you, or your spouse if filing a joint return, want $3 to go to this fund? You:
Yes checkbox checked

Under
Filing Status:

1. Single checkbox checked

Under
Exemptions:

6d. Total number of exemptions claimed. Add numbers on line
above field contains 0